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Lowenkamp M, Eslami MH. The Effect of Social Determinants of Health in Treating Chronic Limb-Threatening Ischemia. Ann Vasc Surg 2024; 107:31-36. [PMID: 38582220 DOI: 10.1016/j.avsg.2023.11.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 11/23/2023] [Indexed: 04/08/2024]
Abstract
Social determinants of health (SDOHs) are broadly defined as nonmedical factors that impact the outcomes of one's health. SDOHs have been increasingly recognized in the literature as profound and modifiable factors on the outcomes of vascular care in peripheral artery disease (PAD) and chronic limb-threatening ischemia (CLTI) despite surgical and technological advancements. In this paper, we briefly review the SDOH and its impact on the management and outcome of patients with CLTI. We highlight the importance of understanding how SDOH impacts our patient population so the vascular community may provide more effective, inclusive, and equitable care.
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Affiliation(s)
- Mikayla Lowenkamp
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Mohammad H Eslami
- Division of Vascular and Endovascular Surgery, Charleston Area Medical Center, Charleston, WV.
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2
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Brown RJL, Treat-Jacobson D, Schorr E, Lindquist R, Pruinelli L, Wolfson J. Symptom Descriptors in Individuals Living With Undiagnosed Lower Extremity Peripheral Artery Disease. West J Nurs Res 2024:1939459241274275. [PMID: 39206689 DOI: 10.1177/01939459241274275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
OBJECTIVE Most individuals with lower extremity peripheral artery disease (PAD) experience symptoms other than claudication and live with undiagnosed PAD yet no tools exist to detect atypical PAD symptoms. The purpose of this study was to identify discriminating PAD symptom descriptors from a community-based sample of patients with no current diagnosis of PAD. METHODS Symptoms descriptors were obtained in a sample of 22 participants with persistent lower extremity symptoms pre/post exercise. An ankle brachial index with exercise was used to classify participants as "PAD" or "No PAD." RESULTS Thirteen (59%) participants had a positive ankle brachial index (<0.9, ≥20% drop postexercise, or 30 mmHg drop postexercise). Symptoms do not disappear while walking, trouble keeping up with friends/family, positive response to pain or discomfort while sitting, and pain outside of the calves and thighs were associated with a positive ankle brachial index. CONCLUSION Atypical symptoms were common among study participants. Symptoms while sitting and symptoms outside of the calf and thigh were negatively associated with a positive ankle brachial index. More precise descriptions of symptom characteristics are needed to improve PAD symptom recognition.
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Affiliation(s)
- Rebecca J L Brown
- Veterans Affairs Health Services Research and Development Center for Care Delivery and Outcomes Research Minneapolis Veterans Affairs Healthcare System, Minneapolis, MN, USA
- University of Minnesota School of Nursing, Minneapolis, MN, USA
| | | | - Erica Schorr
- University of Minnesota School of Nursing, Minneapolis, MN, USA
| | - Ruth Lindquist
- University of Minnesota School of Nursing, Minneapolis, MN, USA
| | - Lisiane Pruinelli
- University of Florida College of Nursing and College of Medicine, Gainesville, FL, USA
| | - Julian Wolfson
- University of Minnesota School of Public Health, Minneapolis, MN, USA
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3
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Farber E, Zhu M, McNamara T, Cheng TW, Alonso A, Siracuse JJ. Patients Experience Significant Long-Term Social and Health Challenges After Major Lower Extremity Amputation. Ann Vasc Surg 2024; 109:291-296. [PMID: 39069122 DOI: 10.1016/j.avsg.2024.07.087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Revised: 07/03/2024] [Accepted: 07/09/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Major lower extremity amputation is a significant life-changing event that can have long-term implications. The goal of this study was to assess long-term medical outcomes and social determinants of health (SDH) challenges in this population. METHODS A retrospective review of major lower extremity (previously mentioned ankle) amputations (2018-2022) was performed at a safety-net tertiary care center. Patients who participated in an SDH survey between 6 months and 1.5 years postoperatively were included for survey analysis. Patient demographics, comorbidities, and perioperative and long-term outcomes were analyzed. RESULTS There were 100 patients included. Mean age was 61.5 years and 23% were of female gender. The majority (57%) were Black race, 20% White race, and 21% Hispanic ethnicity. Comorbidities included diabetes (78%), chronic kidney disease (51%), coronary artery disease (31%), congestive heart failure (23%), previous cerebrovascular events (19%), and 37% used opioids preadmission. At baseline, the majority (62%) lived at home. Guillotine amputation was performed in 24%, with definitive amputation in the following and previously mentioned knee in 67% and 33%, respectively. Median length of stay was 7 days. Readmission at 30 days, 90 days, and 1 year was 13%, 30%, and 43% respectively. The average follow up was 839 days. At long-term follow up, 55% lived at home, 25% used opioids, and only 25% were independently ambulatory. In the SDH survey at follow up, 32% identified at least one SDH challenge, with younger patients more often affected (58 vs. 63 years, P = 0.031). SDH challenges consisted of food insecurity (17%), housing insecurity (13%), transportation challenges (13%), seeking employment (8%), difficulty paying for utilities (5%) and medications (4%), seeking further education (5%), and difficulty caring for family/friends (4%). On multivariable analysis, having at least one SDH challenge was independently associated with 1-year readmission (odds ratio 6.7, 95% confidence interval 1.3-35.8, P < 0.001). Older age was associated with lower long-term independent ambulation (odds ratio 0.92, 95% confidence interval 0.85-0.99, P = 0.025). CONCLUSIONS After major lower extremity amputation, patients have significant medical and social challenges with fewer living at home, the majority were not independently ambulatory, and one-third having at least one SDH challenge. Improvements in long-term support including medical, social, and rehabilitation services are required for this vulnerable population.
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Affiliation(s)
- Elina Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, Chobanian and Avedisian School of Medicine, Boston, MA
| | - Max Zhu
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, Chobanian and Avedisian School of Medicine, Boston, MA
| | - Thomas McNamara
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, Chobanian and Avedisian School of Medicine, Boston, MA
| | - Thomas W Cheng
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, Chobanian and Avedisian School of Medicine, Boston, MA
| | - Andrea Alonso
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, Chobanian and Avedisian School of Medicine, Boston, MA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, Chobanian and Avedisian School of Medicine, Boston, MA.
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Mota L, Jayaram A, Wu WW, Roth EM, Darling JD, Hamdan AD, Wyers MC, Stangenberg L, Schermerhorn ML, Liang P. The impact of travel distance in patient outcomes following revascularization for chronic limb-threatening ischemia. J Vasc Surg 2024:S0741-5214(24)01529-5. [PMID: 39025281 DOI: 10.1016/j.jvs.2024.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 06/30/2024] [Accepted: 07/11/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Patient travel distance to the hospital is a key metric of individual and social disadvantage and its impact on the management and outcomes following intervention for chronic limb-threatening ischemia (CLTI) is likely underestimated. We sought to evaluate the effect of travel distance on outcomes in patients undergoing first-time lower extremity revascularization at our institution. METHODS We retrospectively reviewed all consecutive patients undergoing first-time lower extremity revascularization, both endovascular and open, for CLTI from 2005 to 2014. Patients were stratified into 2 groups based on travel distance from home to hospital greater than or less than 30 miles. Outcomes included reintervention, major amputation, restenosis, primary patency, wound healing, length of stay, length of follow-up and mortality. Kaplan-Meier estimates were used to determine event rates. Logistic and cox regression was used to evaluate for an independent association between travel distance and these outcomes. RESULTS Of the 1293 patients were identified, 38% traveled >30 miles. Patients with longer travel distances were younger (70 years vs 73 years; P = .001), more likely to undergo open revascularization (65% vs 41%; P < .001), and had similar Wound, Ischemia, foot Infection stages (P = .404). Longer distance travelled was associated with an increase in total hospital length of stay (9.6 days vs 8.6 days; P = .031) and shorter total duration of postoperative follow-up (2.1 years vs 3.0 years; P = .001). At 5 years, there was no definitive difference in the rate of restenosis (hzard ratio [HR], 1.3; 95% confidence interval [CI], 0.91-1.9; P = .155) or reintervention (HR, 1.4; 95% CI, 0.96-2.1; P = .065), but longer travel distance was associated with an increased rate of major amputation (HR, 2.1; 95% CI, 1.2-3.7; P = .011), and death (HR, 1.6; 95% CI, 1.2-2.2; P = .002). Longer travel distance was also associated with higher rate of nonhealing wounds (HR, 2.3; 95% CI, 1.5-3.5; P = .001). CONCLUSIONS Longer patient travel distance was found to be associated with a lower likelihood of limb salvage and survival in patients undergoing first-time lower extremity revascularization for CLTI. Understanding and addressing the barriers to discharge, need for multidisciplinary follow-up, and appropriate postoperative wound care management will be key in improving outcomes at tertiary care regional specialty centers.
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Affiliation(s)
- Lucas Mota
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Anusha Jayaram
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Winona W Wu
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Eve M Roth
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Jeremy D Darling
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Allen D Hamdan
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Mark C Wyers
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Lars Stangenberg
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Patric Liang
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA.
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Zhu M, Farber A, King E, Alonso A, Kobzeva-Herzog A, Cooper J, Lotfollahzadeh S, Chitalia VC, Siracuse JJ. Early Kidney Transplantation or Conversion to Peritoneal Dialysis after First-Time Arteriovenous Access Creation. Ann Vasc Surg 2024; 108:57-64. [PMID: 38942372 DOI: 10.1016/j.avsg.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Revised: 06/16/2024] [Accepted: 06/17/2024] [Indexed: 06/30/2024]
Abstract
BACKGROUND After autogenous arteriovenous (AV) access creation for end-stage renal disease, a majority of patients will continue on hemodialysis (HD), a minority will receive definitive treatment with kidney transplantation, and a subset of patients will convert to peritoneal dialysis (PD). Our goal was to identify patient factors associated with early transition from HD to either kidney transplantation or PD. METHODS This is a case-control study of all patients with first-time AV access creation in the Vascular Quality Initiative (2011-2022) who had long-term follow-up. Patients who remained on HD after AV access creation were the control group while patients who received early kidney transplant or who converted to PD were the 2 case groups. Relationship among demographics, comorbidities, neighborhood social disadvantage, and functional status as they relate to renal replacement therapy modality was assessed. RESULTS There were 19,782 patients included; the average age was 62 ± 15 years and 57% were male. During the follow-up period of a median 306 (71-403) days, 1.3% underwent a kidney transplantation and 2.3% underwent conversion to PD. On univariable analysis, rates of kidney transplantation or conversion to PD varied with race (P < 0.001), insurance status (P < 0.001), area deprivation index (ADI) quintile (P < 0.001), and several medical comorbidities. On multivariable analysis, impaired ambulation, current smoking, Medicaid or Medicare insurance, Black race, heart failure, body mass index, and older age were associated with decreased transplantation rates. Conversion to PD was associated with ADI Q5, Q4, and Q3. Decreased conversion to PD was associated with impaired ambulation, Hispanic ethnicity, Black race, former smoking, medication-controlled diabetes, and older age. CONCLUSIONS Decreased kidney transplantation was associated with Black race and noncommercial health insurance but not ADI quintile, suggesting disparities exist beyond community-level access to care. Early kidney transplantation conveyed a 3-year survival benefit compared with HD and PD, which had similar survival. Furthermore work is required to increase access to kidney transplantation and PD.
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Affiliation(s)
- Max Zhu
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Elizabeth King
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Andrea Alonso
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Anna Kobzeva-Herzog
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Jeffrey Cooper
- Division of Transplant Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Saran Lotfollahzadeh
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA; Division of Nephrology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Vipul C Chitalia
- Division of Nephrology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA.
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Mora R, Maze M. The role of cultural competency training to address health disparities in surgical settings. Br Med Bull 2024; 150:42-59. [PMID: 38465857 DOI: 10.1093/bmb/ldae005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/16/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND Disparities in health care delivered to marginalized groups are unjust and result in poor health outcomes that increase the cost of care for everyone. These disparities are largely avoidable and health care providers, have been targeted with education and specialised training to address these disparities. SOURCES OF DATA In this manuscript we have sought out both peer-reviewed material on Pubmed, as well as policy statements on the potential role of cultural competency training (CCT) for providers in the surgical care setting. The goal of undertaking this work was to determine whether there is evidence that these endeavours are effective at reducing disparities. AREAS OF AGREEMENT The unjustness of health care disparities is universally accepted. AREAS OF CONTROVERSY Whether the outcome of CCT justifies the cost has not been effectively answered. GROWING POINTS These include the structure/content of the CCT and whether the training should be delivered to teams in the surgical setting. AREAS TIMELY FOR DEVELOPING RESEARCH Because health outcomes are affected by many different inputs, should the effectiveness of CCT be improvement in health outcomes or should we use a proxy or a surrogate of health outcomes.
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Affiliation(s)
- Roberto Mora
- Department of Anesthesia and Perioperative Care, University of California, 1001 Potrero Avenue, San Francisco, CA 94110, USA
| | - Mervyn Maze
- Department of Anesthesia and Perioperative Care, University of California, 1001 Potrero Avenue, San Francisco, CA 94110, USA
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Sanin GD, Minnick CE, Stutsrim A, Williams TK, Velazquez G, Blazek C, Edwards M, Craven T, Goldman MP. Impact of regional differences and neighborhood socioeconomic deprivation on the outcomes of patients with lower extremity wounds evaluated by a limb-preservation service. J Vasc Surg 2024:S0741-5214(24)01217-5. [PMID: 38782216 DOI: 10.1016/j.jvs.2024.05.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 04/10/2024] [Accepted: 05/16/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVE Management of lower extremity (LE) wounds has evolved with the establishment of specialized limb preservation services. Although clinical factors contribute to limb outcomes, socioeconomic status and community factors also influence the risk for limb loss. The Distressed Community Index (DCI) score is a validated index of social deprivation created to provide an objective measure of economic well-being in United States communities. Few studies have examined the influence of geographic deprivation on outcomes in patients with LE wounds. We examined relationships between socioeconomic deprivation and outcomes of inpatients evaluated by a dedicated limb preservation service (Functional Limb Extremity Service [FLEX]). METHODS Inpatients referred to FLEX over a 5-year period were included. Wound, Ischemia, foot Infection (WIfI) staging was collected. DCI scores were determined using seven indices based on ZIP Code. Outcomes included any minor or major amputations, any endovascular or open LE revascularization, or wound care procedures. Disease etiology, demographic, and anthropometric data were collected. Associations between neighborhood deprivation and limb-specific outcomes were evaluated in models for the DCI and each of its components separately. RESULTS A total of 677 patients were included. Thirty-eight percent were female, with a mean age of 64 years. Sixty percent had WIfI stage 3 or 4 risk of amputation, and 43% had WIfI stage 3 or 4 risk of revascularization. Mean ankle-brachial index and toe pressure were 0.96 (standard deviation [SD], 0.43) and 80 (SD, 57) mmHg. Thirty-five percent were non-White. Amputation was performed in 31% of patients, whereas 17% underwent revascularization. The mean distress score was 64 (SD, 24). Mean DCI scores did not differ across WIfI scores. Likewise, overall DCI distress score was not related to any of the outcomes in univariable or multivariable linear regression models. In univariable linear regression models for amputation, higher poverty rate (odds ratio for SD increase 1.20; 95% confidence interval, 1.02-1.42; P = .025) was significantly associated with the outcome. In multivariable models, neither DCI distress score nor any of its components remained significantly associated with the outcome. CONCLUSIONS Despite known racial disparities in limb-specific outcomes, an aggregate measure of community level distress was not found to be related to outcomes. Although the poverty rate demonstrated a significant relationship with amputation in univariable analysis, this association was not found in multivariable models. Notably, non-White race emerged as a predictor of amputation, underscoring the importance of addressing racial disparities in LE outcomes. Further investigation of potential determinants of LE outcomes is needed, particularly the interaction of such factors with race.
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Affiliation(s)
- Gloria D Sanin
- Department of General Surgery, Wake Forest University School of Medicine, Winston-Salem, NC; Department of Vascular and Endovascular Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, NC.
| | | | - Ashlee Stutsrim
- Department of Vascular and Endovascular Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | - Timothy K Williams
- Department of Vascular and Endovascular Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | - Gabriela Velazquez
- Department of Vascular and Endovascular Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | - Cody Blazek
- Department of Orthopedic Surgery and Rehabilitation, Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | - Matthew Edwards
- Department of Vascular and Endovascular Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | - Timothy Craven
- Division of Public Health Sciences, Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC
| | - Matthew P Goldman
- Department of Vascular and Endovascular Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, NC
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O'Banion LA, Aparicio C, Borshan C, Siada S, Matheny H, Woo K. Improved long-term functional outcomes and mortality of patients with vascular-related amputations utilizing the lower extremity amputation pathway. J Vasc Surg 2024; 79:856-862.e1. [PMID: 38141741 DOI: 10.1016/j.jvs.2023.11.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 11/01/2023] [Accepted: 11/06/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND Enhanced recovery after surgery pathways lead to improve perioperative outcomes for patients with vascular-related amputations; however, long-term data and functional outcomes are lacking. This study evaluated patients treated by the lower extremity amputation pathway (LEAP) and identified predictors of ambulation. METHODS A retrospective review of LEAP patients who underwent major amputation from 2016 to 2022 for Wound, Ischemia, and foot Infection stage V disease was performed. LEAP patients were matched 1:1 with retrospective controls (NOLEAP) by hospital, need for guillotine amputation, and final amputation type (above knee vs below knee). The primary end point was the Medicare Functional Classification Level (K level) (functional classification of patients with amputations) at the last follow-up. RESULTS We included 126 patients with vascular-related amputations (63 LEAP and 63 NOLEAP). Seventy-one percent of the patients were male and 49% were Hispanic with a mean state Area Deprivation Index of 9/10. There were no differences in baseline demographics or comorbidities. All patients had a K level of >0 (ambulatory) before amputation and an average Modified Frailty Index of 4. The median follow-up was 270 days (interquartile range, 84-1234 days) in the NOLEAP group and 369 days (interquartile range, 145-481 days) in the LEAP group. Compared with NOLEAP patients, LEAP patients were more likely to receive a prosthesis (86% vs 44%;P > .001). LEAP patients were more likely to have a K level of >0 (60% vs 25%; P = .003). On multivariable logistic regression, participation in LEAP increased the odds of a K level of >0 at follow-up by 5.8-fold (odds ratio, 5.8; 95% confidence interval, 2.5-13.6). Patients with a K level of >0 had significantly higher survival at 4 years (93% vs 59%; P = .001). In a Cox proportional hazards model, adjusted for demographics, comorbidities and amputation level, a K level of >0 at follow-up was associated with an 88% decrease in the risk of mortality compared with a K level of 0. CONCLUSIONS LEAP leads to improved ambulation with a prosthesis in a socioeconomically disadvantaged and frail patient population. Patients with a K level of >0 (ambulatory) have significantly improved mortality.
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Affiliation(s)
- Leigh Ann O'Banion
- Division of Vascular Surgery, Department of Surgery, University of California San Francisco-Fresno, Fresno, CA. leighann.o'
| | - Carolina Aparicio
- Division of Vascular Surgery, Department of Surgery, University of California San Francisco-Fresno, Fresno, CA
| | - Christian Borshan
- Division of Vascular Surgery, Department of Surgery, University of California San Francisco-Fresno, Fresno, CA
| | - Sammy Siada
- Division of Vascular Surgery, Department of Surgery, University of California San Francisco-Fresno, Fresno, CA
| | - Heather Matheny
- Division of Vascular Surgery, Department of Surgery, University of California San Francisco-Fresno, Fresno, CA
| | - Karen Woo
- Division of Vascular Surgery, Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
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Martin SS, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, Baker-Smith CM, Barone Gibbs B, Beaton AZ, Boehme AK, Commodore-Mensah Y, Currie ME, Elkind MSV, Evenson KR, Generoso G, Heard DG, Hiremath S, Johansen MC, Kalani R, Kazi DS, Ko D, Liu J, Magnani JW, Michos ED, Mussolino ME, Navaneethan SD, Parikh NI, Perman SM, Poudel R, Rezk-Hanna M, Roth GA, Shah NS, St-Onge MP, Thacker EL, Tsao CW, Urbut SM, Van Spall HGC, Voeks JH, Wang NY, Wong ND, Wong SS, Yaffe K, Palaniappan LP. 2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association. Circulation 2024; 149:e347-e913. [PMID: 38264914 DOI: 10.1161/cir.0000000000001209] [Citation(s) in RCA: 124] [Impact Index Per Article: 124.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
BACKGROUND The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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Wu VS, Caputo FJ, Quatromoni JG, Kirksey L, Lyden SP, Rowse JW. Association between socioeconomic deprivation and presentation with a ruptured abdominal aortic aneurysm. J Vasc Surg 2024; 79:44-54. [PMID: 37657685 DOI: 10.1016/j.jvs.2023.08.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/14/2023] [Accepted: 08/26/2023] [Indexed: 09/03/2023]
Abstract
OBJECTIVE Given the ongoing nature of research in the social determinants space and urges to improve United States Preventive Services Task Force screening efforts for abdominal aortic aneurysms (AAAs), this project aims to characterize the association between the level of socioeconomic deprivation, rurality, and ruptured AAA (rAAA) presentation across the United States. METHODS We queried the Vascular Quality Initiative registry (2010-2019) for patients with AAAs. The area deprivation index (ADI) is an index from 1 to 100 used to capture socioeconomic status. ADI was grouped into quintiles, with the most deprived regions being quintile 5 and having the highest ADI index. Multivariable logistic regression assessed the association between ADI, rurality, and rAAA presentation overall and before age 65. RESULTS Of the 82,909 patients included, 11,458 patients (14%) resided in the most socioeconomically deprived regions, and 18,083 patients (22%) lived in rural regions. Overall, 6831 patients (8.2%) experienced an rAAA, with 4696 patients (69%) residing in the three most deprived quintiles. Most patients underwent endovascular repair (n = 67,933; 82%), followed by open repair (n = 14,976; 18%). On multivariable analysis, residence in the most socioeconomically deprived region was associated with a near 1.5-fold increased odds of presenting with an rAAA compared with a residence in the least deprived regions (odds ratio [OR], 1.46; 95% confidence interval [CI], 1.31-1.63; P < .001), whereas urban residence was associated with a decreased odds to present with an rAAA compared with rural residence (OR, 0.84; 95% CI, 0.79-0.89; P < .001). When stratifying the study population by the United States Preventive Services Task Force recommended age for AAA screening (65 years old), 14,147 patients (17%) were under 65. Of those under 65, 1381 patients (9.8%) experienced a rAAA, and 9955 patients (71%) resided in the three most deprived quintiles. Residence in the most socioeconomically deprived region was associated with an increased odds of presenting with an rAAA compared with residence in the least deprived region (OR, 1.31; 95% CI, 1.01-1.69; P = .042). However, there were no significant associations between rural residence and increased rAAA presentation among individuals under 65 (OR, 1.07; 95% CI, 0.93-1.23; P = .36). CONCLUSIONS Among all patients in this study, patients residing in highly socioeconomically deprived or rural regions were more likely to present with an rAAA, but among those under 65, only residence in a socioeconomically deprived area was associated with increased odds of rAAA presentation. Understanding the effects of socioeconomic deprivation on rAAA presentation can identify at-risk populations for early AAA screening before rupture.
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Affiliation(s)
- Victoria S Wu
- Case Western Reserve University School of Medicine, Cleveland, OH.
| | - Francis J Caputo
- Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Jon G Quatromoni
- Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Lee Kirksey
- Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Sean P Lyden
- Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Jarrad W Rowse
- Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, OH
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11
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Hughes K. Sociology begets biology in amputation-revascularization disparities. J Vasc Surg 2024; 79:179-180. [PMID: 38129074 DOI: 10.1016/j.jvs.2023.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 09/10/2023] [Accepted: 09/11/2023] [Indexed: 12/23/2023]
Affiliation(s)
- Kakra Hughes
- Howard University College of Medicine, Washington, DC
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12
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Kassavin D, Mota L, Ostertag-Hill CA, Kassavin M, Himmelstein DU, Woolhandler S, Wang SX, Liang P, Schermerhorn ML, Vithiananthan S, Kwoun M. Amputation Rates and Associated Social Determinants of Health in the Most Populous US Counties. JAMA Surg 2024; 159:69-76. [PMID: 37910120 PMCID: PMC10620677 DOI: 10.1001/jamasurg.2023.5517] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 08/07/2023] [Indexed: 11/03/2023]
Abstract
Importance Social Determinants of Health (SDOH) have been found to be associated with health outcome disparities in patients with peripheral artery disease (PAD). However, the association of specific components of SDOH and amputation has not been well described. Objective To evaluate whether individual components of SDOH and race are associated with amputation rates in the most populous counties of the US. Design, Setting, and Participants In this population-based cross-sectional study of the 100 most populous US counties, hospital discharge rates for lower extremity amputation in 2017 were assessed using the Healthcare Cost and Utilization Project State Inpatient Database. Those data were matched with publicly available demographic, hospital, and SDOH data. Data were analyzed July 3, 2022, to March 5, 2023. Main outcome and Measures Amputation rates were assessed across all counties. Counties were divided into quartiles based on amputation rates, and baseline characteristics were described. Unadjusted linear regression and multivariable regression analyses were performed to assess associations between county-level amputation and SDOH and demographic factors. Results Amputation discharge data were available for 76 of the 100 most populous counties in the United States. Within these counties, 15.3% were African American, 8.6% were Asian, 24.0% were Hispanic, and 49.6% were non-Hispanic White; 13.4% of patients were 65 years or older. Amputation rates varied widely, from 5.5 per 100 000 in quartile 1 to 14.5 per 100 000 in quartile 4. Residents of quartile 4 (vs 1) counties were more likely to be African American (27.0% vs 7.9%, P < .001), have diabetes (10.6% vs 7.9%, P < .001), smoke (16.5% vs 12.5%, P < .001), be unemployed (5.8% vs 4.6%, P = .01), be in poverty (15.8% vs 10.0%, P < .001), be in a single-parent household (41.9% vs 28.6%, P < .001), experience food insecurity (16.6% vs 12.9%, P = .04), or be physically inactive (23.1% vs 17.1%, P < .001). In unadjusted linear regression, higher amputation rates were associated with the prevalence of several health problems, including mental distress (β, 5.25 [95% CI, 3.66-6.85]; P < .001), diabetes (β, 1.73 [95% CI, 1.33-2.15], P < .001), and physical distress (β, 1.23 [95% CI, 0.86-1.61]; P < .001) and SDOHs, including unemployment (β, 1.16 [95% CI, 0.59-1.73]; P = .03), physical inactivity (β, 0.74 [95% CI, 0.57-0.90]; P < .001), smoking, (β, 0.69 [95% CI, 0.46-0.92]; P = .002), higher homicide rate (β, 0.61 [95% CI, 0.45-0.77]; P < .001), food insecurity (β, 0.51 [95% CI, 0.30-0.72]; P = .04), and poverty (β, 0.46 [95% CI, 0.32-0.60]; P < .001). Multivariable regression analysis found that county-level rates of physical distress (β, 0.84 [95% CI, 0.16-1.53]; P = .03), Black and White racial segregation (β, 0.12 [95% CI, 0.06-0.17]; P < .001), and population percentage of African American race (β, 0.06 [95% CI, 0.00-0.12]; P = .03) were associated with amputation rate. Conclusions and Relevance Social determinants of health provide a framework by which the associations of environmental factors with amputation rates can be quantified and potentially used to guide interventions at the local level.
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Affiliation(s)
- Daniel Kassavin
- Division of Vascular Surgery, Cambridge Health Alliance, Cambridge, Massachusetts
| | - Lucas Mota
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Monica Kassavin
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts
| | - David U. Himmelstein
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts
- School of Urban Public Health, City University of New York at Hunter College, New York, New York
| | - Steffie Woolhandler
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts
- School of Urban Public Health, City University of New York at Hunter College, New York, New York
| | - Sophie X. Wang
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Patric Liang
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Marc L. Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Moon Kwoun
- Division of Vascular Surgery, Cambridge Health Alliance, Cambridge, Massachusetts
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13
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Marchak K, Singh D, Malavia M, Trivedi P. A Review of Healthcare Disparities Relevant to Interventional Radiology. Semin Intervent Radiol 2023; 40:427-436. [PMID: 37927511 PMCID: PMC10622245 DOI: 10.1055/s-0043-1775878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
Racial, ethnic, and gender disparities have received focused attention recently, as they became more visible in the COVID era. We continue to learn more about how healthcare disparities manifest for our patients and, more broadly, the structural underpinnings that result in predictable outcomes gaps. This review summarizes what we know about disparities relevant to interventional radiologists. The prevalence and magnitude of disparities are quantified and discussed where relevant. Specific examples are provided to demonstrate how factors like gender, ethnicity, social status, geography, etc. interact to create inequities in the delivery of interventional radiology (IR) care. Understanding and addressing health disparities in IR is crucial for improving real-world patient outcomes and reducing the economic burden associated with ineffective and low-value care. Finally, the importance of intentional mentorship, outreach, education, and equitable distribution of high-quality healthcare to mitigate these disparities and promote health equity in interventional radiology is discussed.
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Affiliation(s)
- Katherine Marchak
- Division of Interventional Radiology, Department of Radiology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Davinder Singh
- Division of Diagnostic Radiology/Department of Radiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Mira Malavia
- University of Missouri, Kansas City School of Medicine, Kansas City, Missouri
| | - Premal Trivedi
- Division of Interventional Radiology, Department of Radiology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
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14
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Zhu M, Mota L, Farber A, Schermerhorn ML, King E, Alonso A, Kobzeva-Herzog A, Morrissey N, Malas M, Siracuse JJ. The impact of neighborhood social disadvantage on presentation and management of first-time hemodialysis access surgery patients. J Vasc Surg 2023; 78:1041-1047.e1. [PMID: 37331447 DOI: 10.1016/j.jvs.2023.05.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 05/24/2023] [Accepted: 05/24/2023] [Indexed: 06/20/2023]
Abstract
OBJECTIVES The impact of social determinants of health on the presentation, management, and outcomes of patients requiring hemodialysis (HD) arteriovenous (AV) access creation have not been well-characterized. The Area Deprivation Index (ADI) is a validated measure of aggregate community-level social determinants of health disparities experienced by members living within a community. Our goal was to examine the effect of ADI on health outcomes for first-time AV access patients. METHODS We identified patients who underwent first-time HD access surgery in the Vascular Quality Initiative between July 2011 to May 2022. Patient zip codes were correlated with an ADI quintile, defined as quintile 1 (Q1) to quintile 5 (Q5) from least to most disadvantaged. Patients without ADI were excluded. Preoperative, perioperative, and postoperative outcomes considering ADI were analyzed. RESULTS There were 43,292 patients analyzed. The average age was 63 years, 43% were female, 60% were of White race, 34% were of Black race, 10% were of Hispanic ethnicity, and 85% received autogenous AV access. Patient distribution by ADI quintile was as follows: Q1 (16%), Q2 (18%), Q3 (21%), Q4 (23%), and Q5 (22%). On multivariable analysis, the most disadvantaged quintile (Q5) was associated with lower rates of autogenous AV access creation (OR, 0.82; 95% confidence interval [CI], 0.74-0.90; P < .001), preoperative vein mapping (OR, 0.57; 95% CI, 0.45-0.71; P < .001), access maturation (OR, 0.82; 95% CI, 0.71-0.95; P = .007), and 1-year survival (OR, 0.81; 95% CI, 0.71-0.91; P = .001) compared with Q1. Q5 was associated with higher 1-year intervention rates than Q1 on univariable analysis, but not on multivariable analysis. CONCLUSIONS The patients undergoing AV access creation who were most socially disadvantaged (Q5) were more likely to experience lower rates of autogenous access creation, obtaining vein mapping, access maturation, and 1-year survival compared with the most socially advantaged (Q1). Improvement in preoperative planning and long-term follow-up may be an opportunity for advancing health equity in this population.
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Affiliation(s)
- Max Zhu
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Lucas Mota
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Elizabeth King
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Andrea Alonso
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Anna Kobzeva-Herzog
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Nicholas Morrissey
- Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian Columbia University Irving Medical Center, New York, NY
| | - Mahmoud Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA.
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15
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Rajani RR. Quantifying disparities in access to care for peripheral artery disease remains a work in progress. J Vasc Surg 2023; 77:1486. [PMID: 37087148 DOI: 10.1016/j.jvs.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 01/03/2023] [Indexed: 04/24/2023]
Affiliation(s)
- Ravi R Rajani
- Emory University School of Medicine, Grady Memorial Hospital, Vascular and Endovascular Surgery, Atlanta, GA
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